Neurosurgeons Express Serious Concerns with Medicare Physician Payment Rules

ko headGuest post from Katie O. Orrico, Esq.
Director, Washington Office
American Association of Neurological Surgeons (AANS)
Congress of Neurological Surgeons (CNS)

On April 27, 2016, the Centers for Medicare & Medicaid Services issued a proposal to overhaul the way Medicare pays physicians. The proposed rule implements key elements of the Medicare Access and CHIP Reauthorization Act (MACRA). This legislation repealed Medicare’s sustainable growth rate (SGR) formula and replaced it with a new payment system. Through a single framework called the “Quality Payment Program,” the new payment paradigm has two paths — the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). The new program consolidates components of three existing Medicare penalty programs — Physician Quality Reporting System (PQRS)Electronic Health Record (EHR) and Value-Based Payment Modifier (VM) — and creates an qualityopportunity for neurosurgeons to earn quality improvement bonus payments.

Responding to the proposal, on June 27, 2016, the AANS and CNS submitted comments to CMS. In the letter, organized neurosurgery expressed serious concerns with the new proposed payment rules and urged CMS to make substantial change before finalizing the payment overhaul. Key topics addressed in the AANS/CNS letter include:

  • Phased Approach and Reasonable Transition Period. The proposed timeline for implementing this major physician payment overhaul is overly ambitious, and the AANS and CNS strongly recommend that CMS adopt a phased approach that includes sufficient time for both clinician education, as well as the collection of updated data on which to set benchmarks. At a minimum, the initial performance period should begin no earlier than July 1, 2017, but ideally not until Jan. 1, 2018.
  • Minimize Reporting Burden. The intent of MACRA was to consolidate and streamline current reporting mandates, yet the CMS proposal continues to perpetuate the flaws of the existing Medicare quality reporting programs. CMS needs to take a more holistic approach than that which is reflected in the proposed rule. For example, participation in a qualified clinical data registry (QCDR) should automatically satisfy multiple MIPS categories, including quality, advancing care information (ACI) and clinical practice improvement activities (CPIA). Additionally, CMS should require reporting on no more than 50 percent of applicable Medicare patients across all measures and reporting mechanisms.
  • Small and Solo Practices Disadvantaged. The majority of physician practices with fewer than 25 clinicians — which reflects most neurosurgical practices — will receive negative payment adjustments under the proposed rule. CMS must take steps to ensure that all physicians, regardless of their specialty or practice, have an equal opportunity to succeed in this new quality payment program. A positive step in this direction would be for CMS to raise the MIPS low-volume exclusion threshold to $30,000 in Medicare allowed charges or fewer than 100 Medicare patients seen by the physician.

In a release coinciding with the submission of comments, AANS president, Frederick A. Boop, MD, FAANS, chair of the department of neurosurgery at the University of Tennessee remarked, “MACRA presents an unprecedented opportunity to fix the currently broken and burdensome Medicare quality programs, which have little meaningful impact on quality and have been extremely disruptive to physician practices.”

CNS president, Russell R. Lonser, MD, FAANS, chair of the department of neurosurgery at The Ohio State University, stated, “CMS should seize this moment and make substantial changes to the proposed rule to ensure that the new quality payment program is patient-centered, flexible and meaningful for physicians and patients alike.” Dr. Lonser added, “The AANS and CNS recognize the enormity of the task to overhaul the Medicare physician payment system. Nevertheless, it is essential that CMS establish the programmatic building blocks that will ensure the quality payment program’s success into the future.”

Copies of the press release and letters neurosurgery-supported are available below:

In the coming weeks and months, the AANS and CNS will be publishing a variety of educational materials to ensure that neurosurgeons are “MACRA ready” and can thrive under the new quality payment program.


Posted in Coding and Reimbursement, Guest Post, Health, MACRA, Medicare, Quality Improvement | Tagged , , , , , , , , , , , , , , , |

AANS Spotlight – ACOs, Mergers and Acquisitions

aansThe AANS Neurosurgeon is the official socioeconomic publication of the American Association of Neurological Surgeons (AANS) and features information and analysis for contemporary neurosurgical practice. It focuses on topics related to legislation, workforce issues and practice management as they affect the specialty of neurosurgery. The June 2016 edition of AANS Neurosurgeon explores the theme, “ACOs, Mergers and Acquisitions,” discussing the impact each can have on the health care industry, specifically neurosurgeons.

ACOs, Mergers and Acquisitions are changing the health care industry and are affecting neurosurgeons in the way they continue to practice their profession and treat patients. Is bigger better? How will a merger affect the quality of patient care? Can a system be large but still keep their focus small to put the needs of each patient first? These questions, along with many others, are answered throughout a series of articles in this publication. As a neurosurgeon, getting involved in the discussion and having a place at the table can help put you in the position to be successful during a changing time in health care as some articles mention. Further, explore the June issue to gain knowledge on the contracting process of a merger or acquisition and weigh-in about how a merger has affected you.

Some highlights of the issue:

Elsewhere in the issue, readers can read additional theme-related articles, as well as book reviews and updates from the AANS/CNS Washington office in the “Washington Watch” column.

Finally, in addition to its regularly updated Twitter page, AANS Neurosurgeon also boasts a Facebook page. Follow both social media accounts to read articles and stay current on the latest neurosurgical news.

Posted in AANS Spotlight, Health, Health Reform, Healthcare Costs, Quality Improvement | Tagged , , , , , |

Distinguished Panel Throws Down the Concussion Gauntlet: AANS Opening Ceremonies

O’NeillGuest post from Brent R. O’Neill, MD
Pediatric Neurosurgeon
University of Colorado, Children’s Hospital Colorado
Aurora, CO

A retired pro-linebacker, an army general, a cable news personality, and a neurosurgeon walk into a bar . . .

Actually, on May 1, 2016, they walked into Chicago’s McCormick Place for the Opening Ceremonies of the 84th AANS Annual Scientific Meeting. The topic tackled, attacked, interrogated and dissected by such a distinguished and diverse panel was, of course, concussion — a subject that has seen an explosion in scientific and media attention over the past decade.

The format was a panel discussion moderated by neurosurgeon and CNN chief medical correspondent Dr. Sanjay Gupta. The panelists represented diverse groups interested in concussion. Jeff Miller, the senior vice president of health and safety for the National Football League (NFL), and Mike Singletary, a long-time Chicago Bears linebacker and NFL Hall-of-Famer, in representing the contact sports arena.

Retired General Peter W. Chiarelli and Geoffrey Ling, MD, PhD, Col. (Ret) represented the military perspective. In recent years, Gen. Chiarelli has taken his military concussion work to the private sector, now serving as CEO of One Mind, a company devoted to benefiting individuals with brain injury and illness through research and advocacy. Col. Ling, a neurocritical care physician with 27 years of army service, also shared his experience, including his work at the Defense Advanced Research Projects Agency (DARPA).

Discussing the perspective of the neuroscience community were Walter J. Koroshetz, MD —  director of the National Institute of Neurological Disorders and Stroke (NINDS) —  and Russell R. Lonser, MD, FAANS —  former chief of the surgical neurology branch at NINDS and current chair of neurosurgery at The Ohio State University Wexner Medical Center.

H. Hunt Batjer, MD, FAANS, AANS president, introduced the panel and framed the discussion. He started with a few well-accepted facts:

  • First, traumatic brain injury (TBI) is a BIG problem;
  • TBI is the leading cause of death and disability among those under 45-years old;
  • Five million Americans currently suffer from TBI-related disability;
  • TBI costs the U.S. economy $76 billion per year; and
  • Sports-related TBI, the vast majority of which are concussions, afflicts 3.8 million individuals each year.

Dr. Batjer also addressed the science related to chronic traumatic encephalopathy (CTE). He noted that CTE can be reliably diagnosed by a collection of phosphorylated tau protein in the perivascular spaces at the depths of sulci on autopsy, but beyond that, there are many unanswered questions.


Pictured from left to right: Mike Singletary; Jeff Miller; Dr. Russell Loner; Col. Geoffrey Ling; Dr. Walter Koroshetz; Gen. Peter Chiarelli; and Dr. Sanjay Gupta.

Early in the event, Singletary described his experience of a concussion from a blindside hit delivered by his former teammate William “Refrigerator” Perry in the 1985 Super Bowl. “It was frustrating and like a blur.”

That comment could aptly describe the state of concussion care today — frustrating for the lack of any established therapy and consensus definition, while at the same time, the media, courts and public opinion play fast and loose with the facts.

The military men on the panel expressed frustration at the lack of progress on the issue. Gen. Chiarelli and One Mind have worked for two years to institute mandatory screening and distribution of concussion information in civilian emergency departments — with little success. In contrast, when he was in the military, he was able to devise a full concussion protocol for the army and to implement it in the front-lines of two war zones in the space of one month.

Col. Ling echoed this frustration, extolling the need for leadership and focus in the scientific community and calling for a scientific strategy to be “targeted, targeted targeted” — a line that drew the most exuberant applause of the evening.

Dr. Koroshetz provided a counterweight to these impassioned pleas. He coolly explained the methodical strategy by which the NINDS is attempting to unravel the challenges of CTE:

  • How to diagnose CTE pre-morbidly (tau positron emission tomography, or PET, scans look promising but still need work);
  • Assessing with a prospective cohort the relationship between severity of symptoms, types of symptoms and severity of pathology; and
  • Study of patient-specific risk factors that can lead to risk-avoidance interventions.

To the NIH approach, Col. Ling added the NFL’s crowd-sourcing efforts and reported the results of two material science challenges. One — which asked the question “Can you come up with a better way to diagnose concussion?” —  garnered 400 submissions. The second challenge aimed to devise concussion mitigating football equipment and yielded over 500 responses, including a start-up helmet company in Seattle and an impact-absorbing artificial turf company in Detroit. All of which serves as a testament, according to Ling, to the societal interest in sports and the ability to leverage that for a cause.

The conversation ranged widely across many topics including:

  • Treating acute concussion;
  • CTE;
  • Teaching proper tackling;
  • Implementing military policy;
  • Football helmet design; and
  • Funding for NIH research.

The night ended on a moment of consensus with all panelists agreeing that they would allow their children to participate in sports that carry a risk of concussion citing the known benefits of team sports. The panel also emphasized the importance of neurosurgery to continue to lead the way in the areas of prevention, treatment and understanding of concussion.

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